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=== Congestive heart failure === Although beta blockers were once contraindicated in [[congestive heart failure]], as they have the potential to worsen the condition due to their effect of decreasing cardiac contractility, studies in the late 1990s showed their efficacy at reducing morbidity and mortality.<ref name="pmid10714728">{{cite journal | vauthors = Hjalmarson A, Goldstein S, Fagerberg B, Wedel H, Waagstein F, Kjekshus J, Wikstrand J, El Allaf D, Vítovec J, Aldershvile J, Halinen M, Dietz R, Neuhaus KL, Jánosi A, Thorgeirsson G, Dunselman PH, Gullestad L, Kuch J, Herlitz J, Rickenbacher P, Ball S, Gottlieb S, Deedwania P | display-authors = 6 | title = Effects of controlled-release metoprolol on total mortality, hospitalizations, and well-being in patients with heart failure: the Metoprolol CR/XL Randomized Intervention Trial in congestive heart failure (MERIT-HF). MERIT-HF Study Group | journal = JAMA | volume = 283 | issue = 10 | pages = 1295–1302 | date = March 2000 | pmid = 10714728 | doi = 10.1001/jama.283.10.1295 | doi-access = free }}</ref><ref name="pmid11835035">{{cite journal | vauthors = Leizorovicz A, Lechat P, Cucherat M, Bugnard F | title = Bisoprolol for the treatment of chronic heart failure: a meta-analysis on individual data of two placebo-controlled studies—CIBIS and CIBIS II. Cardiac Insufficiency Bisoprolol Study | journal = American Heart Journal | volume = 143 | issue = 2 | pages = 301–307 | date = February 2002 | pmid = 11835035 | doi = 10.1067/mhj.2002.120768 }}</ref><ref name="pmid12390947">{{cite journal | vauthors = Packer M, Fowler MB, Roecker EB, Coats AJ, Katus HA, Krum H, Mohacsi P, Rouleau JL, Tendera M, Staiger C, Holcslaw TL, Amann-Zalan I, DeMets DL | display-authors = 6 | title = Effect of carvedilol on the morbidity of patients with severe chronic heart failure: results of the carvedilol prospective randomized cumulative survival (COPERNICUS) study | journal = Circulation | volume = 106 | issue = 17 | pages = 2194–2199 | date = October 2002 | pmid = 12390947 | doi = 10.1161/01.CIR.0000035653.72855.BF | doi-access = free }}</ref> [[Bisoprolol]], [[carvedilol]], and sustained-release [[metoprolol]] are specifically indicated as adjuncts to standard [[ACE inhibitor]] and [[diuretic]] therapy in congestive heart failure, although at doses typically much lower than those indicated for other conditions. Beta blockers are only indicated in cases of compensated, stable congestive heart failure; in cases of acute decompensated heart failure, beta blockers will cause a further decrease in ejection fraction, worsening the patient's current symptoms.{{citation needed|date=September 2023}} Beta blockers are known primarily for their reductive effect on heart rate, although this is not the only mechanism of action of importance in congestive heart failure.<ref>{{Cite journal | vauthors = Fletcher P |title=Beta blockers in heart failure |journal=Australian Prescriber |year=2000 |volume=23 |issue=6 |pages=120–123 |url=https://www.nps.org.au/australian-prescriber/articles/beta-blockers-in-heart-failure |language=en |doi=10.18773/austprescr.2000.138|doi-access=free }}</ref> Beta blockers, in addition to their sympatholytic β<sub>1</sub> activity in the heart, influence the [[renin–angiotensin system]] at the kidneys. Beta blockers cause a decrease in [[renin]] secretion, which in turn reduces the heart oxygen demand by lowering the [[extracellular]] volume and increasing the oxygen-carrying capacity of the blood. Heart failure characteristically involves increased catecholamine activity on the heart, which is responsible for several deleterious effects, including increased oxygen demand, propagation of inflammatory mediators, and abnormal cardiac tissue remodeling, all of which decrease the efficiency of cardiac contraction and contribute to the low ejection fraction.<ref>{{cite web|title = Use of beta-blockers and ivabradine in heart failure with reduced ejection fraction|url = http://www.uptodate.com/contents/use-of-beta-blockers-and-ivabradine-in-heart-failure-with-reduced-ejection-fraction|website = www.uptodate.com|access-date = 2015-12-11|url-status = live|archive-url = https://web.archive.org/web/20151222081646/http://www.uptodate.com/contents/use-of-beta-blockers-and-ivabradine-in-heart-failure-with-reduced-ejection-fraction|archive-date = December 22, 2015|df = mdy-all}}</ref> Beta blockers counter this inappropriately high sympathetic activity, eventually leading to an improved ejection fraction, despite an initial reduction in ejection fraction.{{citation needed|date=October 2023}} Trials have shown beta blockers reduce the absolute risk of death by 4.5% over a 13-month period. In addition to reducing the risk of mortality, the numbers of hospital visits and hospitalizations were also reduced in the trials.<ref name="pmid12173717">{{cite journal | vauthors = Pritchett AM, Redfield MM | title = Beta-blockers: new standard therapy for heart failure | journal = Mayo Clinic Proceedings | volume = 77 | issue = 8 | pages = 839–845; quiz 845–46 | date = August 2002 | pmid = 12173717 | doi = 10.4065/77.8.839 | doi-access = free }}</ref> A 2020 Cochrane review found minimal evidence to support the use of beta blockers in congestive heart failure in children, however did identify that from the data available, that they may be of benefit.<ref>{{cite journal | vauthors = Alabed S, Sabouni A, Al Dakhoul S, Bdaiwi Y | title = Beta-blockers for congestive heart failure in children | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | issue = 7 | pages = CD007037 | date = July 2020 | pmid = 32700759 | pmc = 7389334 | doi = 10.1002/14651858.CD007037.pub4 | collaboration = Cochrane Heart Group }}</ref> Therapeutic administration of beta blockers for congestive heart failure ought to begin at very low doses ({{frac|1|8}} of target) with a gradual escalation of the dose. The heart of the patient must adjust to decreasing stimulation by catecholamines and find a new equilibrium at a lower adrenergic drive.<ref>{{Cite book|title=Goodman & Gilman's: The Pharmacological Basic of Therapeutics|publisher=McGraw-Hill|year=2018|isbn=9781259584732}}</ref> ==== Acute myocardial infarction ==== Beta blockers are indicated for the treatment of acute [[myocardial infarction]]s. During a myocardial infarction, systemic stress causes an increase in circulating [[catecholamine]]s.<ref name="Safi_2019">{{cite journal | vauthors = Safi S, Sethi NJ, Nielsen EE, Feinberg J, Jakobsen JC, Gluud C | title = Beta-blockers for suspected or diagnosed acute myocardial infarction | journal = The Cochrane Database of Systematic Reviews | volume = 12 | issue = 12 | pages = CD012484 | date = December 2019 | pmid = 31845756 | pmc = 6915833 | doi = 10.1002/14651858.CD012484.pub2 | collaboration = Cochrane Heart Group }}</ref><ref name="Farzam_2023">{{cite book | vauthors = Farzam K, Jan A | chapter = Beta Blockers |date=2023 |chapter-url= http://www.ncbi.nlm.nih.gov/books/NBK532906/ | title = StatPearls |access-date=2023-10-31 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=30422501 }}</ref> This results an increase in heart rate and blood pressure, therefore increasing myocardial oxygen demand.<ref name="Farzam_2023" /><ref name="Safi_2019" /> Beta blockers competitively inhibit catecholamines acting on the β<sub>1</sub>-adrenergic receptors, thus reducing these detrimental effects and resulting in reduced myocardial oxygen consumption and demand.<ref name="Safi_2019" /> A 2019 Cochrane review compared beta blockers with [[placebo]] or no intervention, it found that beta blockers probably reduced the short-term risk of reinfarction and the long-term risk of [[all-cause mortality]] and cardiovascular mortality.<ref name="Safi_2019" /> The review identified that beta blockers likely had little to no impact on short-term all-cause mortality and cardiovascular mortality.<ref name="Safi_2019" />
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